Health disparities

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See also: Social determinants of health

Health disparities (also called health inequalities in some countries) refer to gaps in the quality of health and health care across racial, ethnic, and socioeconomic groups.[1] The Health Resources and Services Administration defines health disparities as "population-specific differences in the presence of disease, health outcomes, or access to health care."[2]

In the United States, health disparities are well documented in minority populations such as African Americans, Native Americans, Asian Americans, and Latinos.[3] When compared to whites, these minority groups have higher incidence of chronic diseases, higher mortality, and poorer health outcomes.[4] Among the disease-specific examples of racial and ethnic disparities in the United States is the cancer incidence rate among African Americans, which is 10% higher than among whites.[5] In addition, adult African Americans and Latinos have approximately twice the risk as whites of developing diabetes.[6] Minorities also have higher rates of cardiovascular disease, HIV/AIDS, and infant mortality than whites. (See also: Health care in the United States.)[7]

In Canada, the issue was brought to public attention by the LaLonde report.

In UK, the Black Report report was produced in 1980 to highlight inequalities.

Disparities likely affect hospital rankings[8].

Causes of health disparities

There is debate about what causes health disparities between ethnic and racial groups.[9] However, it is generally accepted that disparities can result from three main areas:

  • From the personal, socioeconomic, and environmental characteristics of different ethnic and racial groups (such as how certain racial groups, on average, live in poorer areas with high incidence of lead-based paint, which can harm children).
  • From the barriers certain racial and ethnic groups encounter when trying to enter into the health care delivery system; and
  • From the quality of health care different ethnic and racial groups receive.[10]

Each of these dimensions have been suggested as possible causes for disparities between racial and ethnic groups. However, most attention on the issue has been given to the health outcomes that result from differences in access to medical care among groups, and the quality of care different groups receive.

Disparities in access to health care

Reasons for disparities in access to health care are many, but can include the following:

  • Lack of insurance coverage. Without health insurance, patients are more likely to postpone medical care, more likely to go without needed medical care, and more likely to go without prescription medicines. Minority groups in the United States lack insurance coverage at higher rates than whites.[11]
  • Lack of a regular source of care. Without access to a regular source of care, patients have greater difficulty obtaining care, fewer doctor visits, and more difficulty obtaining prescription drugs. Compared to whites, minority groups in the United States are less likely to have a doctor they go to on a regular basis and are more likely to use emergency rooms and clinics as their regular source of care.[12]
  • Lack of financial resources. Although the lack of financial resources is a barrier to health care access for many Americans, the impact on access appears to be greater for minority populations.[13]
  • Legal barriers. Access to medical care by low-income immigrant minorities can be hindered by legal barriers to public insurance programs. For example, in the United States federal law bars states from providing Medicaid coverage to immigrants who have been in the country fewer than five years.[14]
  • Structural barriers. These barriers include poor transportation, an inability to schedule appointments quickly or during convenient hours, and excessive time spent in the waiting room, all of which affect a person's ability and willingness to obtain needed care.[15]
  • The health care financing system. The Institute of Medicine in the United States says fragmentation of the U.S. health care delivery and financing system is a barrier to accessing care. Racial and ethnic minorities are more likely to be enrolled in health insurance plans which place limits on covered services and offer a limited number of health care providers.[16]
  • Scarcity of providers. In inner cities, rural areas, and communities with high concentrations of minority populations, access to medical care can be limited due to the scarcity of primary care practitioners, specialists, and diagnostic facilities.[17]
  • Linguistic barriers. Language differences restrict access to medical care for minorities in the United States who are not English-proficient.[18]
  • Health literacy. This is where patients have problems obtaining, processing, and understanding basic health information. For example, patients with a poor understanding of good health may not know when it is necessary to seek care for certain symptoms. While problems with health literacy are not limited to minority groups, the problem can be more pronounced in these groups than in whites due to socioeconomic and educational factors.[19]
  • Lack of diversity in the health care workforce. A major reason for disparities in access to care are the cultural differences between predominantly white health care providers and minority patients. Only 4% of physicians in the United States are African American, and Hispanics represent just 5%, even though these percentages are much less than their groups' proportion of the United States population.[20]

Disparities in quality of health care

Health disparities in the quality of care different ethnic and racial groups receive can include:

  • Problems with patient-provider communication. This communication is critical for the delivery of appropriate and effective treatment and care and, regardless of a patient’s race, miscommunication can lead to an incorrect diagnosis, improper use of medications, and failure to receive follow-up care. Among non-English-speaking populations in the United States, the linguistic barrier is even greater. Less than half of non-English speakers who say they need an interpreter during health care visits report having one. Additional communication problems stem from a lack of cultural understanding on the part of white providers for their minority patients. For example, patient health decisions can be influenced by religious beliefs, mistrust of Western medicine, and familial and hierarchical roles, all of which a white provider may not be familiar with.[21]
  • Provider discrimination. This is where health care providers either unconsciously or consciously treat certain racial and ethnic patients differently than other patients. This may contribute to therapeutic inertia. Some research suggests that minorities are less likely than whites to receive a kidney transplant once on dialysis or to receive pain medication for bone fractures. Critics question this research and say further studies are needed to determine how doctors and patients make their treatment decisions. Others argue that certain diseases cluster by ethnicity and that clinical decision making does not always reflect these differences.[22]
  • Hypertension control. Among patients with hypertension, the rate of control is less among African-Americans[23].

Disparities among the healthcare workforce

Unions

Unionization of healthcare workers may reduce inequities in pay[24].


Ending health disparities

Startifying data analyses by vulnerable populations may help identify opportunities to end disparities[25]

The Commonwealth Fund, in a report on how to eliminate health disparities, says that the following steps should be considered in developing policies to eliminate racial and ethnic disparities:[26]

  • Consistent racial and ethnic data collection by health care providers.
  • Effective evaluation of disparities-reduction programs.
  • Minimum standards for culturally and linguistically competent health services.
  • Greater minority representation within the health care workforce.
  • Establishment or enhancement of government offices of minority health.
  • Expanded access to services for all ethnic and racial groups.
  • Involvement of all health system representatives in minority health improvement efforts.

A systematic review found that the following interventions were effective[27]:

  • housing
  • income support
  • nutrition support
  • care coordination
  • community outreach


Reducing hospitalizations and emergency department visits

The ECHO (Extension for Community Health Outcomes) program may improve the care of U.S. patients with Medicaid[28].

Improving preventive care

The Agency for Healthcare Research and Quality has reviewed strategies to improve preventive care[29].

See also

References

  1. ↑ U.S. Department of Health and Human Services (HHS), Healthy People 2010: National Health Promotion and Disease Prevention Objectives, conference ed. in two vols (Washington, D.C., January 2000).
  2. ↑ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 3.
  3. ↑ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004).
  4. ↑ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), pages 4-5.
  5. ↑ American Public Health Association (APHA), Eliminating Health Disparities: Toolkit (2004).
  6. ↑ American Public Health Association (APHA), Eliminating Health Disparities: Toolkit (2004).
  7. ↑ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), pages 4-5.
  8. ↑ Bae, Jonathan A.; Curtis, Lesley H.; Hernandez, Adrian F. (2020). "National Hospital Quality Rankings". JAMA. doi:10.1001/jama.2020.11165. ISSN 0098-7484.
  9. ↑ Henry J. Kaiser Family Foundation (KFF), "A Synthesis of the Literature: Racial and Ethnic Differences in Access to Medical Care" (October 1999).
  10. ↑ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), pages 6-7.
  11. ↑ Kaiser Commission on Medicaid and the Uninsured (KCMU), "The Uninsured and Their Access to Health Care" (December 2003).
  12. ↑ G. E. Fryer, S. M. Dovey, and L. A. Green, "The Importance of Having a Usual Source of Health Care," American Family Physician 62 (2000): 477.
  13. ↑ Commonwealth Fund (CMWF), "Analysis of Minority Health Reveals Persistent, Widespread Disparities," press release (May 14, 1999).
  14. ↑ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 10.
  15. ↑ Agency for Healthcare Research and Quality (AHRQ), "National Healthcare Disparities Report," U.S. Department of Health and Human Services (July 2003).
  16. ↑ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 10.
  17. ↑ K. Collins, D. Hughes, M. Doty, B. Ives, J. Edwards, and K. Tenney, "Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans," Commonwealth Fund (March 2002).
  18. ↑ National Health Law Program and the Access Project (NHeLP), Language Services Action Kit: Interpreter Services in Health Care Settings for People With Limited English Proficiency (February 2004).
  19. ↑ K. Collins, D. Hughes, M. Doty, B. Ives, J. Edwards, and K. Tenney, "Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans," Commonwealth Fund (March 2002).
  20. ↑ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 13.
  21. ↑ Goldberg, J., Hayes, W., and Huntley, J. "Understanding Health Disparities." Health Policy Institute of Ohio (November 2004), page 14.
  22. ↑ B. Smedley, A. Stith, and A. Nelson, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care," Institute of Medicine (2002).
  23. ↑ Yoon SS, Carroll MD, Fryar CD (2015). "Hypertension Prevalence and Control Among Adults: United States, 2011-2014". NCHS Data Brief (220): 1–8. PMID 26633197.
  24. ↑ Ahmed AM, Kadakia K, Ahmed A, Shultz B, Li X (2022). "Trends in Labor Unionization Among US Health Care Workers, 2009-2021". JAMA. 328 (24): 2404–2411. doi:10.1001/jama.2022.22790. PMID 36573974 Check |pmid= value (help).
  25. ↑ Sivashanker, Karthik; Gandhi, Tejal K. (2020). "Advancing Safety and Equity Together". New England Journal of Medicine. 382 (4): 301–303. doi:10.1056/NEJMp1911700. ISSN 0028-4793.
  26. ↑ J. McDonough, B. Gibbs, J. Scott-Harris, K. Kronebusch, A. Navarro, and K. A. Taylor, "State Policy Agenda to Eliminate Racial and Ethnic Health Disparities," Commonwealth Fund (June 2004).
  27. ↑ Taylor LA, Tan AX, Coyle CE, Ndumele C, Rogan E, Canavan M; et al. (2016). "Leveraging the Social Determinants of Health: What Works?". PLoS One. 11 (8): e0160217. doi:10.1371/journal.pone.0160217. PMC 4988629. PMID 27532336.
  28. ↑ Komaromy M, Bartlett J, Gonzales-van Horn SR, Zurawski A, Kalishman SG, Zhu Y; et al. (2020). "A Novel Intervention for High-Need, High-Cost Medicaid Patients: a Study of ECHO Care". J Gen Intern Med. 35 (1): 21–27. doi:10.1007/s11606-019-05206-0. PMID 31667743.
  29. ↑ Nelson HD, Cantor A, Wagner J, Jungbauer R, Quiñones A, Fu R; et al. (2019). "Achieving Health Equity in Preventive Services". AHRQ Comparative Effectiveness Reviews. PMID 31841291.

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